Article excerpt

The intent of this response is to alert the reader to some still unresolved issues in understanding the complex phenomenon of death in a health care system where sophisticated technology enhances our medical capabilities and contributes to previously unknown ethical dilemmas for patients, families, and health professionals.

The Wolf study explores the lived experiences and hidden or invisible work of nurses who provide care for transplant donors before, during, and after organ procurement. These nurses work within a complex and dynamic web of human relationships at the nexus of life-death-life, that is, the life and death of the donor, and the lives of the donor's family, other health professionals, and organ recipients. Both nurses and physicians struggle with the profound ethical issues and uncertainties involved in organ procurement, as dead patients are treated in many ways as if they were still alive (Youngner et al. 1985). This study is an important contribution to the literature of nursing and medicine, as attention must be paid to the subjective experiences of health professionals in order to establish systems of care delivery that are sensitive to care and support needs of patients (donors and potential recipients), their families, and support of health professionals, in this instance, nurses.

Organ transplantation is recognized in this study as a technological innovation that precludes a more peaceful death for patients who are "transformed" into organ donors as they move from machine-supported life and brain death to death following organ procurement. Nurses who care for these patients experience conflict and suffering, as they identify with families and even in some instances with donors. They recognize implicitly (if not explicitly) the incongruity of caring for what they describe as the living/dead. Ethical, legal, social, spiritual, psychological, cultural and other aspects contribute to these conflicts as nurses deal with the still profound mystery of death in the course of human experience. It is important to note that these conflicts arise in a specific cultural milieu that views death generally as a tragedy. This is not the view of all cultures.

In this study, nurses report that they serve roles such as "standing in" for the family and serving as temporary kin to the family of the organ donor in the process of organ procurement and care of the body after surgery for organ removal. In a sense, these nurses are also "standing in" as expert, respectful, and caring members of the wider human community, the broader context of nursing care and obligation that extends to organ donors, recipients, and their families. Study respondents also see themselves as "protectors" of the donor and recipient as they participate in the rituals and procedures that surround organ procurement. One might say that these nurses have a "covenant" of protection with both the donor and recipient through the life/death/life process. In these roles, nurses, too, experience the tragedy of suffering and unexpected death of recently healthy persons and need to feel that something good comes out of such tragic occurrences. They, too, struggle with balancing the tragedy of a donor's death with the gift of life to the organ recipient.

Death of the organ donor is perceived differently from the death of others, as nurses report seeing the donor as a "sacred being." This perception is not explored further in Wolfs study but needs clarification of its meaning for nurses and of how, if at all, these feelings affect care of organ donors and other patients. Are brain-dead patients who become donors perceived as requiring special or different nursing care, other than specific technical requirements of care necessary for the organ procurement process because they are defined as "sacred beings"? Does this translate into special or even supererogatory nursing obligations or benefits that other patients do not receive when all patients are to be regarded as equally worthy of respect and as having inherent dignity? …